We interact with many different groups of coworkers throughout the day. Maintaining professionalism with each of these groups, showing respect for each other and the work that we all do recognizes that without the support of each person on this team, we will not be able to provide the best care possible for the patient for whom we are caring. Let us take a closer look at these groups and common interactions that occur.
As a reminder, each of us was probably a volunteer, a high school student, or college student shadowing a physician at one point. Our dream to become a physician started many years before we arrived at the point when we were caring for patients directly. Encouraging those who are younger than we are or early in their career path is an important piece of professionalism. If you have the opportunity to show a volunteer a new procedure or an x-ray image, that will inspire them and encourage them.
We now turn to discuss a few case examples of difficult situations that place a physician or physician in training in a precarious position. We explore these cases for ideas of what can be done and how to approach a similar situation if it should arise. We hope you never have to face these situations. However, you will undoubtedly have to face similar and perhaps more difficult decisions in your career, which will test your ability to remain professional and simultaneously act as a team member in the best interest of your patients. Remember, the behavior you learn and practice now will likely affect how you act as a physician into the future.
The problem: Aspiring medical student dissuaded by professor.
The story: Nadia, a junior in college, was well on her way to completing her premed major. She enrolled in a small seminar course called “What it’s like to be a patient, What it’s like to be a physician.” She was so excited for the course because she believed that finally she would be closer to her goal of seeing what it was truly like to be a physician. She had spent countless hours studying biology, genetics, anatomy, organic chemistry, and so on, and she couldn’t wait to take a course that would really expose her to the experience of being a physician and taking care of patients.
Nadia started that course full of enthusiasm, which unfortunately slowly fizzled away. Suddenly she was no longer interested in being a doctor, and she couldn’t understand why. In the seminar they were reading narratives about patient experiences that were extremely moving, and meeting with physicians who told powerful stories of lives changed and the meaning and purpose they had found in their careers. While they discussed the challenges of medical training and the medical field, they also were exposed to the magic and power of medicine. Despite all of this, at the end of the course, Nadia decided that medicine wasn’t for her and she walked away from her premed choice. Her family and friends were shocked and she couldn’t explain to them why she had made this decision. She had wanted to be a doctor since she was 13 years old and now suddenly it just didn’t feel right.
Nadia graduated from college and spent the summer after college traveling. When she returned, she had hoped she would have some direction regarding the profession that she wanted to pursue. She spent hours meeting with family and friends discussing her experiences in college and traveling and everyone kept telling her the same thing: “You still want to be a doctor. You should go and be a doctor.” She heard all of that but still couldn’t shake her experience during the seminar course. So Nadia contacted the professor of the seminar course and went to meet with him. It was during this meeting, that she finally understood the feeling she had during the course when the professor was finally honest with her. He told her, “I don’t think you have what it takes to be a doctor and I don’t think you will make a good doctor. I seriously think you should consider another career.”
The outcome: She had spent months thinking that she didn’t want to be a doctor because it wasn’t right for her when in reality it was just that one current doctor didn’t think she should be a doctor. All that despite what so many family and friends had told her. This professor was never honest with her or supported her in her goals as a professional should. In the end, she returned to medicine. She applied to medical school and was accepted into many of the top medical schools in the country. She graduated medical school and completed residency and is currently working in academic medicine. Nadia is not only a successful physician with many patients who love and respect her, but she also is educating future physicians and supporting them in their goals.
This story illustrates that people who are early on their medical career paths can be easily influenced by those who are already on that path. Physicians should maintain professionalism and support volunteers, high school students, and college students who are in the medical facilities getting exposure to the field; these individuals need to be encouraged to continue developing their skills. This professor, in subtle and unprofessional ways, influenced the student and almost took her completely away from her passion based on his opinion of her. Ultimately, he was wrong and she followed her true passion, resulting in a successful career in medicine.
There is a hierarchy in medicine, one that is very clear. Attending → Fellow → Chief Resident → Resident → Intern → Medical Student. There is a reason for this hierarchy and it has to do with knowledge and training. But despite being higher than someone else on the career ladder, it is not okay to be unprofessional with those below. Historically, harsh treatment of interns and medical students has been common practice using techniques such as pimping, berating, and scut work. However, this does not create an environment conducive to learning and that is the reason each person is there.
The problem: Medical students experience unprofessional behaviors.
The story: A physician who worked at the local school of medicine described a shocking conversation she had with a group of medical students. She was their professor for the Problem-Based Learning course and had built a strong relationship with this group of 11 medical students over the previous 4 years of their education. She had heard rumors on campus of poor treatment of medical students and awful experiences that had occurred but was having a hard time believing that things happened as the rumors described.
In their final class meeting, she sat down to have a frank discussion about any unprofessional behavior that the students had personally experienced. She wasn’t expecting the response that she received. She asked. They answered. Of the 11 fourth-year medical students in her group, 1 shared that he was currently being tested for hepatitis C. Why? He was the in the OR observing an operation on a patient with hepatitis C when one of the surgeons in the room threw the scalpel at him and stuck him. A second medical student shared that she too had witnessed unprofessional behavior after a surgical resident got upset with what she was doing and sutured her gloves to the patient as punishment. Both students hadn’t reported the experience because they didn’t want to get a bad grade on the rotation. The descriptions of these experiences are absolutely appalling. Yet despite that, these are the experiences of medical students currently in training.
Most physicians believe that these experiences are only part of training and that once training is finished, unprofessional behavior will not occur because they are now attendings. However, that is not that case. Many attending physicians tell stories of interactions with residents and attending physicians in which the behavior demonstrated is very unprofessional if not downright criminal.
The problem: Unknown doctor attempts to overtake patient care and berates attending physician’s decisions in front of colleagues and patient.
The story: A patient checked into an outpatient clinic, located within a hospital with a chief complaint of left leg deep vein thrombosis (DVT). The intern went to perform the initial evaluation on the patient. The presentation of the intern was that this patient was a 40-year-old man with a history of Factor V Leiden who was on warfarin. The patient had been taking his warfarin but hadn’t had his international normalized ratio (INR) checked in several months. The patient stated that he had called his hematologist who told him to present for further evaluation and treatment. The patient complained of a few days of left leg swelling without pain and mild redness. Per the intern, the exam was mild left leg swelling, 1 cm greater than the right, mild erythema, and negative Homan’s. As such, the decision was made to order an INR as the first step in the evaluation. If the INR was therapeutic, no further intervention was necessary. If the INR was subtherapeutic, the next step would be to proceed with an ultrasound. The INR came back at 1.41, subtherapeutic, so an ultrasound was ordered.
While awaiting the ultrasound, an unknown physician walked into the clinic workspace without introduction. The attending running the clinic turned to the unknown physician and asked if she could help him. He stated that he was looking for the above patient so she directed him to the room the patient was in. The unknown physician returned to the clinic workspace just as ultrasound called for the patient to go to ultrasound. He interrupted the attending as she was staffing another patient with a resident, and directed her to give the patient an enoxaparin shot. She explained that the patient was just called for ultrasound and that enoxaparin would have to be ordered from the inpatient pharmacy and that would take 30 to 45 minutes to obtain. He then said that it was fine to go to ultrasound and left the clinic. She was a little surprised by another physician coming into the clinic and directing patient care without explanation but didn’t think much of it.
The patient went to ultrasound and when he returned, the treating physician received a call from the radiologist that the patient had a left leg DVT from the left iliac to left popliteal vein. It was read as nonocclusive and likely chronic. The clinic attending physician went and talked with the patient who told her that he had just been too busy to get his INR checked and that he would like an enoxaparin shot in the clinic before leaving. He reported that he would follow up with his hematologist on the outside for further decision making and monitoring. He reported recent changes in a dietary supplement that may have affected his INR. As such, she ordered the patient to be weighed and then with the weight, ordered enoxaparin from the inpatient pharmacy.
The unknown physician returned and stormed into the clinic workspace. He again interrupted the attending physician while she was discussing a case with the residents. He stated, “Why didn’t my patient get enoxaparin?” She told him that the enoxaparin had been ordered and as the clinic didn’t have it in the Pyxis, they had to wait for it to be sent from pharmacy. He stated, “I told you to order it before he went to ultrasound.” She replied that she needed an accurate weight in order to place the order. He replied, “You had a weight because you got it when he checked in, I don’t know what kind of clinic you are running!” She replied that the clinic didn’t get weights when people checked in and she needed him to get back from ultrasound in order to have the accurate weight. The unknown physician became more and more frustrated and argumentative in the clinic workspace. He stated, “I can’t believe you wouldn’t give him enoxaparin the minute he presented as he clearly has a DVT.” She replied that she used a stepwise cost-effective approach in the care of the patient and that she didn’t prescribe enoxaparin, or any other medication, until she is sure that is the appropriate course of management. He then yelled, “So you didn’t give him the enoxaparin because of cost. Is that what kind of medicine you practice? I can’t believe that. He has insurance. Now he has been sitting here for 3 hours in the clinic probably with his clot breaking off and traveling to his lungs and I’m going to have to do something about it!” The clinic attending physician replied that it wasn’t a cost issue and that she was taking a thoughtful approach to the patient. He stated, “I don’t know what you were thinking.” He then brought the argument to the clinic director where the argument ensued.
Upon the attending physician’s return to the clinic workspace, she was notified that the patient had received the enoxaparin shot. As such, she wrote him a prescription for more enoxaparin and wrote for his discharge with follow-up with his outside hematologist. The charge nurse went and discharged the patient. She reported that as she approached the room, she heard the unknown physician telling the patient that he didn’t get the enoxaparin sooner because of a cost issue. Despite all of that, the charge nurse stated that the patient was very grateful for his care and he felt it was appropriate. He told her that his wife worked with the unknown physician and that they had “butted heads” multiple times. He stated that he had asked the unknown physician to tone it down and that he was very embarrassed by his behavior. The patient thanked the charge nurse for the care he received and left the clinic.
This interaction was extremely unprofessional on many levels. While the 2 physicians may have had different opinions on the best management approach for this patient, it is not appropriate for the unknown physician to come into a clinic without introduction and direct the care of the patient. Nor is it appropriate for him to be so confrontational with the clinic attending physician in the middle of the clinic workspace and in front of all of the staff. And finally it was necessary for the unknown physician to degrade the care to the patient directly.
This scenario could play out in many different ways in your future. It will be critical to maintain composure as you balance a patient-centered approach with evidence-based medicine, safe practices, and competing demands. You will have the ability to control your own communication and reactions while acknowledging that you cannot control those of others. As you continue in your career you will have the chance to learn and grow if you allow yourself an element of vulnerability—your vulnerable patients will be beneficiaries.